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Casanova-Ferrer F, Gallego JJ, Fiorillo A, Urios A, Ríos MP, León JL, Ballester MP, Escudero-García D, Kosenko E, Belloch V, Montoliu C. Improved cognition after rifaximin treatment is associated with changes in intra- and inter-brain network functional connectivity. J Transl Med 2024; 22:49. [PMID: 38217008 PMCID: PMC10787503 DOI: 10.1186/s12967-023-04844-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/29/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Rifaximin is a non-reabsorbable antibiotic which acts at gut level, and improves cognition and inflammatory parameters in minimal hepatic encephalopathy (MHE) patients, but not all patients show the same level of response. This study aims to assess brain activity, both within and between brain networks, following rifaximin treatment, considering the differences between response groups as well. METHODS Twenty-two healthy controls and 53 patients with cirrhosis (22 without and 31 with MHE, diagnosed by Psychometric Hepatic Encephalopathy Score, PHES) performed psychometric, attention and coordination tests, and blood inflammatory parameters were measured. Resting-state functional magnetic resonance imaging (fMRI) acquisitions were performed on controls and MHE patients. Eighteen MHE patients underwent a rifaximin treatment for 6 months, after which all measures were repeated. fMRI images were analysed and changes after treatment were assessed. RESULTS After rifaximin treatment, 13 patients improved their PHES score (Responder patients) while 5 did not (Non-responder patients). No significant decrease in blood ammonia was observed after rifaximin treatment, but there was a decrease in plasma inflammatory cytokines in responder patients. A global effect of rifaximin was detected on the sensorimotor and fronto-parietal networks. Responder patients showed a relative increase of thalamic network connectivity in comparison to non-responder patients. Before treatment, responder and non-responder patients showed connectivity differences in basal ganglia network. The connection of the sensorimotor and thalamic networks between them and with other networks suffered changes after treatment. These connections between networks mostly decreased after treatment. All changes and differences showed a significant level of correlation with the performance of psychometric tests and the blood levels of inflammatory biomarkers. CONCLUSIONS There was an improvement of the communication between executive, motor and attention-related brain areas, and their functional independence following rifaximin treatment. Patients who respond also show a less deteriorated connection involved in these functions before treatment. Results suggest that the improved inflammatory state of MHE patients, following rifaximin treatment would favour the observed changes in brain function and enhanced cognitive performance.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Juan-José Gallego
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Alessandra Fiorillo
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - Amparo Urios
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain
| | - María-Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova de Valencia, Valencia, Spain
| | - José Luis León
- Universitats Neurorradiology Unit, Ascires Biomedical Group, Valencia, Spain
| | - María-Pilar Ballester
- Servicio de Medicina Digestiva, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Desamparados Escudero-García
- Servicio de Medicina Digestiva, Hospital Clinico Universitario de Valencia, Valencia, Spain
- Departamento de Medicina, University of Valencia, Valencia, Spain
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, Pushchino, Russia
| | - Vicente Belloch
- Universitats Neurorradiology Unit, Ascires Biomedical Group, Valencia, Spain
| | - Carmina Montoliu
- Fundacion de Investigación Hospital Clinico Universitario de Valencia-INCLIVA, Valencia, Spain.
- Department of Pathology, Faculty of Medicine, University of Valencia, Av Blasco Ibáñez, 15, 46010, Valencia, Spain.
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Ji J, Liu YY, Wu GW, Hu YL, Liang CH, Wang XD. Changes in dynamic and static brain fluctuation distinguish minimal hepatic encephalopathy and cirrhosis patients and predict the severity of liver damage. Front Neurosci 2023; 17:1077808. [PMID: 37056312 PMCID: PMC10086246 DOI: 10.3389/fnins.2023.1077808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
PurposeMinimal hepatic encephalopathy (MHE) is characterized by mild neuropsychological and neurophysiological alterations that are not detectable by routine clinical examination. Abnormal brain activity (in terms of the amplitude of low-frequency fluctuation (ALFF) has been observed in MHE patients. However, little is known concerning temporal dynamics of intrinsic brain activity. The present study aimed to investigate the abnormal dynamics of brain activity (dynamic ALFF; dALFF) and static measures [static ALFF; (sALFF)] in MHE patients and to strive for a reliable imaging neuromarkers for distinguishing MHE patients from cirrhosis patients. In addition, the present study also investigated whether intrinsic brain activity predicted the severity of liver damage.MethodsThirty-four cirrhosis patients with MHE, 28 cirrhosis patients without MHE, and 33 age-, sex-, and education-matched healthy controls (HCs) underwent resting-state magnetic resonance imaging (rs-fMRI). dALFF was estimated by combining the ALFF method with the sliding-window method, in which temporal variability was quantized over the whole-scan timepoints and then compared among the three groups. Additionally, dALFF, sALFF and both two features were utilized as classification features in a support vector machine (SVM) to distinguish MHE patients from cirrhosis patients. The severity of liver damage was reflected by the Child–Pugh score. dALFF, sALFF and both two features were used to predict Child–Pugh scores in MHE patients using a general linear model.ResultsCompared with HCs, MHE patients showed significantly increased dALFF in the left inferior occipital gyrus, right middle occipital gyrus, and right insula; increased dALFF was also observed in the right posterior lobe of the cerebellum (CPL) and right thalamus. Compared with HCs, noMHE patients exhibited decreased dALFF in the right precuneus. In contrast, compared with noMHE patients, MHE patients showed increased dALFF in the right precuneus, right superior frontal gyrus, and right superior occipital gyrus. Furthermore, the increased dALFF values in the left precuneus were positively associated with poor digit-symbol test (DST) scores (r = 0.356, p = 0.038); however, dALFF in the right inferior temporal gyrus (ITG) was negatively associated with the number connection test–A (NCT-A) scores (r = -0.784, p = 0.000). A significant positive correlation was found between dALFF in the left inferior occipital gyrus (IOG) and high blood ammonia levels (r = 0.424, p = 0.012). Notably, dALFF values yielded a higher classification accuracy than sALFF values in distinguishing MHE patients from cirrhosis patients. Importantly, the dALFF values predicted the Child–Pugh score (r = 0.140, p = 0.030), whereas sALFF values did not in the current dataset. Combining two features had high accuracy in classification in distinguishing MHE patients from cirrhotic patients and yielded prediction in the severity of liver damage.ConclusionThese findings suggest that combining dALFF and sALFF features is a useful neuromarkers for distinguishing MHE patients from cirrhosis patients and highlights the important role of dALFF feature in predicting the severity of liver damage in MHE.
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Affiliation(s)
- Jiang Ji
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China
- Department of Radiology, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
| | - Yi-yang Liu
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guo-Wei Wu
- Chinese Institute for Brain Research, Beijing, China
| | - Yan-Long Hu
- Department of Radiology, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
| | - Chang-Hua Liang
- Department of Radiology, The First Affiliated Hospital of Xinxiang Medical College, Xinxiang, China
- *Correspondence: Chang-Hua Liang,
| | - Xiao-dong Wang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China
- Xiao-dong Wang,
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Czarnecka AM, Obara-Michlewska M, Wesół-Kucharska D, Greczan M, Kaczor M, Książyk J, Rokicki D, Zielińska M. S100B Protein but Not 3-Nitrotyrosine Positively Correlates with Plasma Ammonia in Patients with Inherited Hyperammonemias: A New Promising Diagnostic Tool? J Clin Med 2023; 12:jcm12062411. [PMID: 36983411 PMCID: PMC10056255 DOI: 10.3390/jcm12062411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/15/2023] [Accepted: 03/17/2023] [Indexed: 03/30/2023] Open
Abstract
Individuals with inherited hyperammonemias often present developmental and intellectual deficiencies which are likely to be exaggerated by hyperammonemia episodes in long-term outcomes. In order to find a new, systemic marker common to the course of congenital hyperammonemias, we decided to measure the plasma level of S100 calcium-binding protein B (S100B), which is associated with cerebral impairment. Further, we analyzed three mechanistically diverged but linked with oxidative-nitrosative stress biochemical parameters: 3-nitrotyrosine (3-NT), a measure of plasma proteins' nitration; advanced oxidation protein products (AOPP), a measure of protein oxidation; and glutathione peroxidase (GPx) activity, a measure of anti-oxidative enzymatic capacity. The plasma biomarkers listed above were determined for the first time in congenital hyperammonemia. Also, the level of pro- and anti-inflammatory mediators (i.e., IL-12, IL-6, IL-8, TNF-α, IL-1β, and IL-10) and chemokines (IP-10, MCP-1, MIG, and RANTES) were quantified. S100B was positively correlated with plasma ammonia level, while noticeable levels of circulating 3-NT in some of the patients' plasma did not correlate with ammonia concentration. Overall, the linear correlation between ammonia and S100B but not standard oxidative stress-related markers offers a unique perspective for the future identification and monitoring of neurological deficits risk-linked with hyperammonemia episodes in patients with inherited hyperammonemias. The S100B measure may support the development of therapeutic targets and clinical monitoring in these disorders.
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Affiliation(s)
- Anna Maria Czarnecka
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
| | - Marta Obara-Michlewska
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
| | - Dorota Wesół-Kucharska
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Milena Greczan
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Magdalena Kaczor
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Janusz Książyk
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Dariusz Rokicki
- Department of Pediatrics, Nutrition, and Metabolic Diseases, Children's Memorial Health Institute, Al. Dzieci Polskich 20, 04-730 Warsaw, Poland
| | - Magdalena Zielińska
- Department of Neurotoxicology, Mossakowski Medical Research Institute Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland
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Cellular Pathogenesis of Hepatic Encephalopathy: An Update. Biomolecules 2023; 13:biom13020396. [PMID: 36830765 PMCID: PMC9953810 DOI: 10.3390/biom13020396] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/01/2023] [Accepted: 02/17/2023] [Indexed: 02/22/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric syndrome derived from metabolic disorders due to various liver failures. Clinically, HE is characterized by hyperammonemia, EEG abnormalities, and different degrees of disturbance in sensory, motor, and cognitive functions. The molecular mechanism of HE has not been fully elucidated, although it is generally accepted that HE occurs under the influence of miscellaneous factors, especially the synergistic effect of toxin accumulation and severe metabolism disturbance. This review summarizes the recently discovered cellular mechanisms involved in the pathogenesis of HE. Among the existing hypotheses, ammonia poisoning and the subsequent oxidative/nitrosative stress remain the mainstream theories, and reducing blood ammonia is thus the main strategy for the treatment of HE. Other pathological mechanisms mainly include manganese toxicity, autophagy inhibition, mitochondrial damage, inflammation, and senescence, proposing new avenues for future therapeutic interventions.
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Huang G, Xie S, Wang M, Mao D, Huang G, Huang J, Liu X, Zhang R, Xie J, Huang LJ, Cheng C, Yao F, Zhong Y, Lin L, Yao C. Metabolite profiling analysis of hepatitis B virus-induced liver cirrhosis patients with minimal hepatic encephalopathy using gas chromatography-time-of-flight mass spectrometry and ultra-performance liquid chromatography-quadrupole-time-of-flight mass spectrometry. Biomed Chromatogr 2023; 37:e5529. [PMID: 36250932 DOI: 10.1002/bmc.5529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 12/15/2022]
Abstract
This study used gas chromatography-time-of-flight mass spectrometry (GC-TOFMS) and ultra-performance liquid chromatography-quadrupole TOFMS (UPLC-QTOFMS) metabonomic analytical techniques in combination with bioinformatics and pattern recognition analysis methods to analyze the serum metabolite profiling of hepatitis B virus (HBV)-induced liver cirrhosis patients with minimal hepatic encephalopathy (MHE), to find the specific biomarkers of MHE, to reveal the pathogenesis of MHE, and to determine a promising approach for early diagnosis of MHE. Serum samples of 100 normal controls (NC group), 29 HBV-induced liver cirrhosis patients with MHE (MHE group), and 24 HBV-induced liver cirrhosis patients without MHE [comprising 12 cases of compensated cirrhosis (CS group) and 12 cases of decompensated cirrhosis (DS group)] were collected and employed into GC-TOFMS and UPLC-QTOFMS platforms for serum metabolite detection; the outcome data were then analyzed using principal component analysis and orthogonal partial least squares-discriminant analysis (OPLS-DA). There were no significant differential metabolites between the NC group and the CS group. A series of key differential metabolites were detected. According to the variable influence in projection values and P-values, 60 small-molecule metabolites were considered to be dysregulated in the MHE group (compared to the NC group); 27 of these 60 dysregulated differential metabolites were considered to be the potential biomarkers (see Table 4, marked in bold); 66 small-molecule metabolites were considered to be dysregulated in the DS group (compared to the NC group); 34 of these 66 dysregulated differential metabolites were considered to be the potential biomarkers (see Table 5, marked in bold). According to the fold-change values, 9 of these 27 metabolites, namely valine, oxalic acid, erythro-sphingosine, 4,7,10,13,16,19-docosahexaenoic acid, isoleucine, allo-isoleucine, thyroxine, rac-octanoyl carnitine, and tocopherol (vitamin E), were downregulated in the MHE group (compared to the NC group); the other 18, namely adenine, glycochenodeoxycholic acid, fucose, allothreonine, glycohyocholic acid, glycoursodeoxycholic acid, tyrosine, taurocheno-deoxycholate, phenylalanine, 2-hydroxy-3-methyl-butanoic acid, hydroxyacetic acid, taurocholate, sorbitol, rhamnose, tauroursodeoxycholate, tolbutamide, pyroglutamic acid, and malic acid, were upregulated; 6 of these 34 metabolites were downregulated in the DS group (compared to the NC group), and the other 28 were upregulated, as shown in Table 5. (a) GC-TOFMS and UPLC-QTOFMS metabonomic analytical platforms can detect a range of metabolites in the serum; this might be of great help to study the pathogenesis of MHE and may provide a new approach for the early diagnosis of MHE. (b) Metabonomics analysis in combination with pattern recognition analysis might have great potential to distinguish the HBV-induced liver cirrhosis patients who have MHE from the normal healthy population and HBV-induced liver cirrhosis patients without MHE.
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Affiliation(s)
- Guochu Huang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Sheng Xie
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Meng Wang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Dewen Mao
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Guye Huang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Jingjing Huang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Xirong Liu
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Rongzhen Zhang
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Jiacheng Xie
- Guangxi University of Chinese Medicine, Nanning, China
| | | | - Chen Cheng
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Fan Yao
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Yu Zhong
- First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning, China
| | - Long Lin
- Guangxi University of Chinese Medicine, Nanning, China
| | - Chun Yao
- Guangxi University of Chinese Medicine, Nanning, China
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Minimal Hepatic Encephalopathy Affects Daily Life of Cirrhotic Patients: A Viewpoint on Clinical Consequences and Therapeutic Opportunities. J Clin Med 2022; 11:jcm11237246. [PMID: 36498820 PMCID: PMC9736966 DOI: 10.3390/jcm11237246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is a frequent complication of hepatic encephalopathy (HE) and can affect up to 80% of patients with liver cirrhosis. It is characterized by the lack of obvious clinical signs and the presence of alterations detectable using psychometric or electrophysiological testing focused on attention, working memory, psychomotor speed and visuospatial ability. Ideally, each patient should be tested for this condition because, despite the absence of symptoms, it has severe repercussions on daily life activities. It may be responsible for an inability to drive, sleep disturbances, risk of falls and inability to work. Some studies have highlighted its prognostically unfavorable role on mortality and risk of "overt" HE (OHE). Finally, MHE severely affects the lives of patients and caregivers, altering their quality of life and their socioeconomic status. Several treatments have been proposed for MHE treatment, including non-absorbable disaccharides, poorly absorbable antibiotics, such as rifaximin, probiotics and branched-chain amino acids, with promising results. For this reason, early diagnosis and intervention with appropriate measures is essential, with the aim of improving both performance on psychometric tests, as well as clinical aspects related to this condition.
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Casanova-Ferrer F, García-Cena CE, Gallego JJ, Fiorillo A, Urios A, Calvo-Córdoba A, Ballester MP, Ríos MP, Durbán L, Hidalgo MR, García F, Felipo V, Montoliu C. Minimal hepatic encephalopathy is associated to alterations in eye movements. Sci Rep 2022; 12:16837. [PMID: 36207472 PMCID: PMC9547018 DOI: 10.1038/s41598-022-21230-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
Minimal hepatic encephalopathy (MHE) is diagnosed using PHES battery, but other tests are more sensitive, and a simple tool for early MHE detection is required. Assessment of saccadic eye movements is useful for early detection of cognitive alterations in different pathologies. We characterized the alterations in saccadic eye movements in MHE patients, its relationship with cognitive alterations and its utility for MHE diagnosis. One-hundred and eighteen cirrhotic patients (86 without and 32 with MHE) and 35 controls performed PHES and Stroop test and an eye movements test battery by OSCANN system: visual saccades, antisaccades, memory-guided saccades, fixation test and smooth pursuit. We analyzed 177 parameters of eye movements, assessed their diagnostic capacity for MHE, and correlated with cognitive alterations. MHE patients showed alterations in 56 of the 177 variables of eye movements compared to NMHE patients. MHE patients showed longer latencies and worse performance in most eye movements tests, which correlated with mental processing speed and attention impairments. The best correlations found were for antisaccades and memory-guided saccades, and some parameters in these tests could be useful for discriminating MHE and NMHE patients. Eye movements analysis could be a new, rapid, reliable, objective, and reproducible tool for early diagnose MHE.
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Affiliation(s)
- Franc Casanova-Ferrer
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Cecilia E García-Cena
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Juan-Jose Gallego
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alessandra Fiorillo
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Amparo Urios
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain
| | - Alberto Calvo-Córdoba
- Centre for Automation and Robotics, Universidad Politecnica de Madrid, Madrid, Spain
| | - Maria-Pilar Ballester
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain.,Servicio de Medicina Digestiva, Hospital Clínico Universitario de Valencia, 46010, Valencia, Spain
| | - María Pilar Ríos
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Lucía Durbán
- Servicio de Medicina Digestiva, Hospital Arnau de Vilanova, 46015, Valencia, Spain
| | - Marta R Hidalgo
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Francisco García
- Bioinformatics and Biostatistics Unit, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe, 46012, Valencia, Spain
| | - Carmina Montoliu
- Fundación de Investigación Hospital Clínico Universitario de Valencia-INCLIVA, 46010, Valencia, Spain. .,Department of Pathology, Faculty of Medicine, University of Valencia/INCLIVA-Health Research Institute, Avda. Blasco Ibañez, 17, 46010, Valencia, Spain.
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Arenas YM, Martínez-García M, Llansola M, Felipo V. Enhanced BDNF and TrkB Activation Enhance GABA Neurotransmission in Cerebellum in Hyperammonemia. Int J Mol Sci 2022; 23:ijms231911770. [PMID: 36233065 PMCID: PMC9570361 DOI: 10.3390/ijms231911770] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Hyperammonemia is a main contributor to minimal hepatic encephalopathy (MHE) in cirrhotic patients. Hyperammonemic rats reproduce the motor incoordination of MHE patients, which is due to enhanced GABAergic neurotransmission in the cerebellum as a consequence of neuroinflammation. In hyperammonemic rats, neuroinflammation increases BDNF by activating the TNFR1–S1PR2–CCR2 pathway. (1) Identify mechanisms enhancing GABAergic neurotransmission in hyperammonemia; (2) assess the role of enhanced activation of TrkB; and (3) assess the role of the TNFR1–S1PR2–CCR2–BDNF pathway. In the cerebellum of hyperammonemic rats, increased BDNF levels enhance TrkB activation in Purkinje neurons, leading to increased GAD65, GAD67 and GABA levels. Enhanced TrkB activation also increases the membrane expression of the γ2, α2 and β3 subunits of GABAA receptors and of KCC2. Moreover, enhanced TrkB activation in activated astrocytes increases the membrane expression of GAT3 and NKCC1. These changes are reversed by blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway. Hyperammonemia-induced neuroinflammation increases BDNF and TrkB activation, leading to increased synthesis and extracellular GABA, and the amount of GABAA receptors in the membrane and chloride gradient. These factors enhance GABAergic neurotransmission in the cerebellum. Blocking TrkB or the TNFR1–SP1PR2–CCL2–CCR2–BDNF–TrkB pathway would improve motor function in patients with hepatic encephalopathy and likely with other pathologies associated with neuroinflammation.
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Montagnese S, Rautou PE, Romero-Gómez M, Larsen FS, Shawcross DL, Thabut D, Vilstrup H, Weissenborn K. EASL Clinical Practice Guidelines on the management of hepatic encephalopathy. J Hepatol 2022; 77:807-824. [PMID: 35724930 DOI: 10.1016/j.jhep.2022.06.001] [Citation(s) in RCA: 127] [Impact Index Per Article: 63.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 12/12/2022]
Abstract
The EASL Clinical Practice Guidelines (CPGs) on the management of hepatic encephalopathy (HE) present evidence-based answers to a set of relevant questions (where possible, formulated in PICO [patient/population, intervention, comparison and outcomes] format) on the definition, diagnosis, differential diagnosis and treatment of HE. The document does not cover the pathophysiology of HE and does not cover all available treatment options. The methods through which it was developed and any information relevant to its interpretation are also provided.
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Mincheva G, Gimenez-Garzo C, Izquierdo-Altarejos P, Martinez-Garcia M, Doverskog M, Blackburn TP, Hällgren A, Bäckström T, Llansola M, Felipo V. Golexanolone, a GABA A receptor modulating steroid antagonist, restores motor coordination and cognitive function in hyperammonemic rats by dual effects on peripheral inflammation and neuroinflammation. CNS Neurosci Ther 2022; 28:1861-1874. [PMID: 35880480 PMCID: PMC9532914 DOI: 10.1111/cns.13926] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 11/29/2022] Open
Abstract
Aims Hyperammonemic rats show peripheral inflammation, increased GABAergic neurotransmission and neuroinflammation in cerebellum and hippocampus which induce motor incoordination and cognitive impairment. Neuroinflammation enhances GABAergic neurotransmission in cerebellum by enhancing the TNFR1‐glutaminase‐GAT3 and TNFR1‐CCL2‐TrkB‐KCC2 pathways. Golexanolone reduces GABAA receptors potentiation by allopregnanolone. This work aimed to assess if treatment of hyperammonemic rats with golexanolone reduces peripheral inflammation and neuroinflammation and restores cognitive and motor function and to analyze underlying mechanisms. Methods Rats were treated with golexanolone and effects on peripheral inflammation, neuroinflammation, TNFR1‐glutaminase‐GAT3 and TNFR1‐CCL2‐TrkB‐KCC2 pathways, and cognitive and motor function were analyzed. Results Hyperammonemic rats show increased TNFα and reduced IL‐10 in plasma, microglia and astrocytes activation in cerebellum and hippocampus, and impaired motor coordination and spatial and short‐term memories. Treating hyperammonemic rats with golexanolone reversed changes in peripheral inflammation, microglia and astrocytes activation and restored motor coordination and spatial and short‐term memory. This was associated with reversal of the hyperammonemia‐enhanced activation in cerebellum of the TNFR1‐glutaminase‐GAT3 and TNFR1‐CCL2‐TrkB‐KCC2 pathways. Conclusion Reducing GABAA receptors activation with golexanolone reduces peripheral inflammation and neuroinflammation and improves cognitive and motor function in hyperammonemic rats. The effects identified would also occur in patients with hepatic encephalopathy and, likely, in other pathologies associated with neuroinflammation.
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Affiliation(s)
- Gergana Mincheva
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carla Gimenez-Garzo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - Mar Martinez-Garcia
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | | | | | - Torbjörn Bäckström
- Umecrine Cognition AB, Solna, Sweden.,Umeå Neurosteroid Research Center, Clinical Sciences at Umeå University, Umeå, Sweden
| | - Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
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11
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Häussinger D, Butz M, Schnitzler A, Görg B. Pathomechanisms in hepatic encephalopathy. Biol Chem 2021; 402:1087-1102. [PMID: 34049427 DOI: 10.1515/hsz-2021-0168] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/12/2021] [Indexed: 02/06/2023]
Abstract
Hepatic encephalopathy (HE) is a frequent neuropsychiatric complication in patients with acute or chronic liver failure. Symptoms of HE in particular include disturbances of sensory and motor functions and cognition. HE is triggered by heterogeneous factors such as ammonia being a main toxin, benzodiazepines, proinflammatory cytokines and hyponatremia. HE in patients with liver cirrhosis is triggered by a low-grade cerebral edema and cerebral oxidative/nitrosative stress which bring about a number of functionally relevant alterations including posttranslational protein modifications, oxidation of RNA, gene expression changes and senescence. These alterations are suggested to impair astrocyte/neuronal functions and communication. On the system level, a global slowing of oscillatory brain activity and networks can be observed paralleling behavioral perceptual and motor impairments. Moreover, these changes are related to increased cerebral ammonia, alterations in neurometabolite and neurotransmitter concentrations and cortical excitability in HE patients.
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Affiliation(s)
- Dieter Häussinger
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Markus Butz
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
| | - Boris Görg
- Clinic for Gastroenterology, Hepatology, and Infectious Diseases, Heinrich Heine University, Moorenstr. 5, D-40225 Düsseldorf, Germany
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12
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Rega D, Aiko M, Peñaranda N, Urios A, Gallego JJ, Giménez-Garzó C, Casanova F, Fiorillo A, Cabrera-Pastor A, San-Miguel T, Ipiens C, Escudero-García D, Tosca J, Montón C, Ballester MP, Ballester J, Aparicio L, Ríos MP, Durbán L, Mir A, Kosenko E, Cases P, Felipo V, Montoliu C. Patients with Minimal Hepatic Encephalopathy Show Altered Thermal Sensitivity and Autonomic Function. J Clin Med 2021; 10:jcm10020239. [PMID: 33440769 PMCID: PMC7826803 DOI: 10.3390/jcm10020239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 12/21/2022] Open
Abstract
Cirrhotic patients may experience alterations in the peripheral nervous system and in somatosensory perception. Impairment of the somatosensory system could contribute to cognitive and motor alterations characteristic of minimal hepatic encephalopathy (MHE), which affects up to 40% of cirrhotic patients. We assessed the relationship between MHE and alterations in thermal, vibration, and/or heat pain sensitivity in 58 cirrhotic patients (38 without and 20 with MHE according to Psychometric Hepatic Encephalopathy Score) and 39 controls. All participants underwent attention and coordination tests, a nerve conduction study, autonomic function testing, and evaluation of sensory thresholds (vibration, cooling, and heat pain detection) by electromyography and quantitative sensory testing. The detection thresholds for cold and heat pain on the foot were higher in patients with, than those without MHE. This hyposensitivity was correlated with attention deficits. Reaction times in the foot were longer in patients with, than without MHE. Patients with normal sural nerve amplitude showed altered thermal sensitivity and autonomic function, with stronger alterations in patients with, than in those without MHE. MHE patients show a general decrease in cognitive and sensory abilities. Small fibers of the autonomic nervous system and thermal sensitivity are altered early on in MHE, before large sensory fibers. Quantitative sensory testing could be used as a marker of MHE.
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Affiliation(s)
- Dalia Rega
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Mika Aiko
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Nicolás Peñaranda
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Amparo Urios
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Juan-José Gallego
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Carla Giménez-Garzó
- Laboratorio de Neurobiología. Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (V.F.)
| | - Franc Casanova
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Alessandra Fiorillo
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Andrea Cabrera-Pastor
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
| | - Teresa San-Miguel
- Departamento de Patología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Cristina Ipiens
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Desamparados Escudero-García
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Joan Tosca
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - Cristina Montón
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - María-Pilar Ballester
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - José Ballester
- Servicio de Medicina Digestiva, Hospital Clinico de Valencia, 46010 Valencia, Spain; (D.E.-G.); (J.T.); (C.M.); (J.B.)
| | - Luis Aparicio
- Departamento de Anatomía y Embriología, Universidad Valencia, 46010 Valencia, Spain;
| | - María-Pilar Ríos
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (M.-P.R.); (L.D.)
| | - Lucía Durbán
- Servicio de Digestivo, Hospital Arnau de Vilanova, 46015 Valencia, Spain; (M.-P.R.); (L.D.)
| | - Amparo Mir
- Departamento de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
| | - Elena Kosenko
- Institute of Theoretical and Experimental Biophysics of Russian Academy of Sciences, 142290 Pushchino, Russia;
| | - Paula Cases
- Servicio de Neurofisiología, Hospital Clínico de Valencia, 46010 Valencia, Spain; (M.A.); (N.P.); (C.I.); (P.C.)
| | - Vicente Felipo
- Laboratorio de Neurobiología. Centro Investigación Príncipe Felipe, 46012 Valencia, Spain; (C.G.-G.); (V.F.)
| | - Carmina Montoliu
- INCLIVA, Health Research Institute, 46010 Valencia, Spain (A.U.); (J.-J.G.); (F.C.); (A.F.); (A.C.-P.); (M.-P.B.)
- Departamento de Patología, Facultad de Medicina, Universidad de Valencia, 46010 Valencia, Spain;
- Correspondence: ; Tel.: +34-963-864-381
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Alsebaey A. Prediction of minimal encephalopathy in patients with HCV-related cirrhosis using albumin-bilirubin, platelets-albumin-bilirubin score, albumin-bilirubin-platelets grade and ammonia level. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-0023-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
Minimal hepatic encephalopathy (MHE) is a complication of liver cirrhosis causing low quality of life, driving skills and higher traffic violation. The neuro-psychometric tests are the gold standard but difficult clinically and time-consuming. The aim was to assess albumin-bilirubin (ALBI), platelets-albumin-bilirubin (PALBI) score, albumin-bilirubin-platelets (ALBI-PLT) grade and ammonia level as MHE predictors. All the patients (n = 257) underwent critical flicker frequency number connection, serial dotting and digit symbol test for MHE diagnosis (n = 166, 64.6%). Liver function, INR, CBC and arterial ammonia were measured.
Results
There was statistically significant difference (p < 0.05) between MHE patients and those without as regards ammonia (86.59 ± 23.25 vs. 63.56 ± 24.2 μmol/L), ALBI score (−2.13 ± 0.53 vs. −2.49 ± 0.38), PALBI score (−2.33 ± 0.39 vs. −2.55 ± 0.26) and ALBI-PLT (3.98 ± 0.49 vs. 3.70 ± 0.56). Patients with MHE were mainly Child-Pugh B and C and also ALBI grade 2 and 3. For MHE discrimination, ALBI, PALBI, ALBI-PLT and ammonia had the following cutoffs >−2.36 (57.23% sensitivity, 77.78% specificity), >−2.5 (60.84% sensitivity, 67.9% specificity), > 3 (87.35% sensitivity, 27.16% specificity) and > 76.5 (69% sensitivity, 72.5% specificity) respectively (p = 0.001). On comparison of the area under the curve, ALBI is comparable to PALBI (p = 0.245) and ammonia (p = 0.603). The ALBI-PLT is inferior to ALBI (p = 0.018) and ammonia (p = 0.021) but comparable to PALBI (p = 0.281). ALBI (odds = 5.64), PALBI (odds = 7.86), ALBI-PLT (odds = 2.86), ammonia (odds = 1.05), Child-Pugh score (odds = 2.13), MELD (odds = 1.26) are independent predictors of MHE.
Conclusion
ALBI, PALBI and ammonia are clinical useful model for MHE prediction.
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Bajaj JS, Lauridsen M, Tapper EB, Duarte-Rojo A, Rahimi RS, Tandon P, Shawcross DL, Thabut D, Dhiman RK, Romero-Gomez M, Sharma BC, Montagnese S. Important Unresolved Questions in the Management of Hepatic Encephalopathy: An ISHEN Consensus. Am J Gastroenterol 2020; 115:989-1002. [PMID: 32618647 DOI: 10.14309/ajg.0000000000000603] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Management of hepatic encephalopathy (HE) remains challenging from a medical and psychosocial perspective. Members of the International Society for Hepatic Encephalopathy and Nitrogen Metabolism recognized 5 key unresolved questions in HE management focused on (i) driving, (ii) ammonia levels in clinical practice, (iii) testing strategies for covert or minimal HE, (iv) therapeutic options, and (v) nutrition and patient-reported outcomes. The consensus document addresses these topical issues with a succinct review of the literature and statements that critically evaluate the current science and practice, laying the groundwork for future investigations.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University, McGuire VA Medical Center, Richmond, Virginia, USA
| | | | | | | | | | | | | | - Dominique Thabut
- Paris Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Radha K Dhiman
- Postgraduate Institute of Medical Education & Research, Chandigarh, India
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15
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Kerbert AJC, Jalan R. Recent advances in understanding and managing hepatic encephalopathy in chronic liver disease. F1000Res 2020; 9. [PMID: 32399191 PMCID: PMC7194462 DOI: 10.12688/f1000research.22183.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2020] [Indexed: 12/12/2022] Open
Abstract
Hepatic encephalopathy (HE) is a common, severe complication of advanced chronic liver disease (CLD) and has a devastating impact on the patient’s quality of life and prognosis. The neurotoxin ammonia and the presence of systemic and neurological inflammation are considered the key drivers of this neuropsychiatric syndrome. Treatment options available in routine clinical practice are limited, and the development of novel therapies is hampered owing to the complexity and heterogeneity of HE. This review article aims to outline the current understanding of the pathomechanisms of HE and the recent advances in the identification and development of novel therapeutic targets.
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Affiliation(s)
- Annarein J C Kerbert
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Rajiv Jalan
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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16
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KASL clinical practice guidelines for liver cirrhosis: Varices, hepatic encephalopathy, and related complications. Clin Mol Hepatol 2020; 26:83-127. [PMID: 31918536 PMCID: PMC7160350 DOI: 10.3350/cmh.2019.0010n] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 02/06/2023] Open
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17
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Cabrera‐Pastor A, Llansola M, Montoliu C, Malaguarnera M, Balzano T, Taoro‐Gonzalez L, García‐García R, Mangas‐Losada A, Izquierdo‐Altarejos P, Arenas YM, Leone P, Felipo V. Peripheral inflammation induces neuroinflammation that alters neurotransmission and cognitive and motor function in hepatic encephalopathy: Underlying mechanisms and therapeutic implications. Acta Physiol (Oxf) 2019; 226:e13270. [PMID: 30830722 DOI: 10.1111/apha.13270] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 12/11/2022]
Abstract
Several million patients with liver cirrhosis suffer minimal hepatic encephalopathy (MHE), with mild cognitive and coordination impairments that reduce their quality of life and life span. Hyperammonaemia and peripheral inflammation act synergistically to induce these neurological alterations. We propose that MHE appearance is because of the changes in peripheral immune system, which are transmitted to brain, leading to neuroinflammation that alters neurotransmission leading to cognitive and motor alterations. We summarize studies showing that MHE in cirrhotic patients is associated with alterations in the immune system and that patients died with HE show neuroinflammation in cerebellum, with microglial and astrocytic activation and Purkinje cell loss. We also summarize studies in animal models of MHE on the role of peripheral inflammation in neuroinflammation induction, how neuroinflammation alters neurotransmission and how this leads to cognitive and motor alterations. These studies identify therapeutic targets and treatments that improve cognitive and motor function. Rats with MHE show neuroinflammation in hippocampus and altered NMDA and AMPA receptor membrane expression, which impairs spatial learning and memory. Neuroinflammation in cerebellum is associated with altered GABA transporters and extracellular GABA, which impair motor coordination and learning in a Y maze. These alterations are reversed by treatments that reduce peripheral inflammation (anti-TNFα, ibuprofen), neuroinflammation (sulphoraphane, p38 inhibitors), GABAergic tone (bicuculline, pregnenolone sulphate) or increase extracellular cGMP (sildenafil or cGMP). The mechanisms identified would also occur in other chronic diseases associated with inflammation, aging and some mental and neurodegenerative diseases. Treatments that improve MHE may also be beneficial to treat these pathologies.
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Affiliation(s)
- Andrea Cabrera‐Pastor
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
- Fundacion Investigacion Hospital Clinico Valencia, INCLIVA Valencia Spain
| | - Marta Llansola
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Carmina Montoliu
- Fundacion Investigacion Hospital Clinico Valencia, INCLIVA Valencia Spain
| | - Michele Malaguarnera
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Tiziano Balzano
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Lucas Taoro‐Gonzalez
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Raquel García‐García
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Alba Mangas‐Losada
- Fundacion Investigacion Hospital Clinico Valencia, INCLIVA Valencia Spain
| | | | - Yaiza M. Arenas
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Paola Leone
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
| | - Vicente Felipo
- Laboratory of Neurobiology Centro de Investigación Principe Felipe Valencia Spain
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18
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Haeger P, Bouchet A, Ossandon C, Bresky G. Treatment with Melatonin Improves Cognitive Behavior and Motor Skills in a Rat Model of Liver Fibrosis. Ann Hepatol 2019; 18:101-108. [PMID: 31113577 DOI: 10.5604/01.3001.0012.7867] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 01/22/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Patients with liver cirrhosis (LC) and minimal hepatic encephalopaty have a higher accident rate. LC impairs the normal sleep-awake cycle and produces disturbances in behavior, cognition and motor skills. Abnormal melatonin (MT) levels have also been identified in LC. Administration of MT may regulate circadian rhythms and prevent the oxidative damage. We studied the effects of MT on spatial memory acquisition (SMA) and motor skills in a liver fibrosis model (LF)s. MATERIALS AND METHODS Forty-five rats, divided into 4 groups. [G1: LF; G2: LF + MT; G3: MT; G4: Healthy control (HC)]. LF was induced by carbon tetrachloride intraperitoneal injection (0.2 mL/kg) for 5 months. MT was administered during 5 weeks (0.4 mg/kg/day). SMA was evaluated by using the Morris Water Maze protocol where the escape latency (EL) and mean speed were measured. Data were registered by SMART®. RESULTS The EL measurement analyzed by two way ANOVA: cirrhosis presented a higher EL than controls or those treated with MT suggesting impaired memory acquisition which is rescued by MT treatment. The mean speed analysis revealed that LF presented higher speed than LF+MT or HC, suggesting that LF affects motor skills, which are improved by MT. To discard whether EL is affected by altered motor skills in LF treated with MT, we compared the average EL and speed between days 2 and 6 of the training protocol. Speed was not improved during the trials unlike EL, suggesting that memory acquisition is independent of motor skills. CONCLUSION These findings suggest that MT improves cognition and motor skills in the LF model.
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Affiliation(s)
- Paola Haeger
- Department of Biomedical Sciences. Faculty of Medicine. Universidad Catolica del Norte. Coquimbo. Chile
| | - Antoine Bouchet
- Department of Biomedical Sciences. Faculty of Medicine. Universidad Catolica del Norte. Coquimbo. Chile
| | - Carolina Ossandon
- Department of Biomedical Sciences. Faculty of Medicine. Universidad Catolica del Norte. Coquimbo. Chile
| | - Gustavo Bresky
- Department of Biomedical Sciences. Faculty of Medicine. Universidad Catolica del Norte. Coquimbo. Chile.
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Urios A, Mangas-Losada A, Gimenez-Garzó C, González-López O, Giner-Durán R, Serra MA, Noe E, Felipo V, Montoliu C. Altered postural control and stability in cirrhotic patients with minimal hepatic encephalopathy correlate with cognitive deficits. Liver Int 2017; 37:1013-1022. [PMID: 27988985 DOI: 10.1111/liv.13345] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 12/07/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Cognitive dysfunction in cirrhotic patients with minimal hepatic encephalopathy (MHE) is associated with falls. Alterations in postural control and stability could contribute to increase falls risk in these patients. We aimed to assess whether postural control and direction-specific limits of stability are altered in cirrhotic patients with MHE compared to patients without MHE and controls. We also assessed if alterations in postural control correlate with neurological impairment and/or blood biomarkers. METHODS Posturography analysis, attention Stroop test and bimanual and visuo-motor coordination tests were performed in 18 controls, 19 patients with cirrhosis without MHE and 17 with MHE, diagnosed by PHES. Posturography was assessed by NedSVE® /IBV system under four sensory conditions. Limits of stability and rhythmic weight-shifting tests were also performed. Blood ammonia and serum interleukins were also measured. Falls were assessed after 12-24 months follow-up. RESULTS MHE patients show impaired balance, mainly on unstable surface with eyes open, with longer reaction and confinement times and lower success in Limits of Stability test compared to patients without MHE. Performance in attention and motor coordination tests correlated with most posturography parameters alterations. Logistic regression analysis shows that posturography parameters and bimanual coordination test are good predictors of falls. CONCLUSION Balance patterns and limits of stability in MHE patients are impaired compared to patients without MHE and controls. This seems to contribute to a higher falls risk. Attention and motor coordination deficits could contribute to balance impairment in patients with MHE.
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Affiliation(s)
- Amparo Urios
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | | | - Carla Gimenez-Garzó
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | | | | | - Miguel A Serra
- Unidad de Digestivo, Hospital Clínico de Valencia, Departamento Medicina, Universidad de Valencia, Valencia, Spain
| | - Enrique Noe
- Servicio de Daño, Cerebral del Hospital Valencia al Mar, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro Investigación Príncipe Felipe de Valencia, Valencia, Spain
| | - Carmina Montoliu
- Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain.,Departamento de Patología, Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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20
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Agusti A, Llansola M, Hernández-Rabaza V, Cabrera-Pastor A, Montoliu C, Felipo V. Modulation of GABAA receptors by neurosteroids. A new concept to improve cognitive and motor alterations in hepatic encephalopathy. J Steroid Biochem Mol Biol 2016; 160:88-93. [PMID: 26307490 DOI: 10.1016/j.jsbmb.2015.08.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 08/14/2015] [Accepted: 08/19/2015] [Indexed: 12/28/2022]
Abstract
Hepatic encephalopathy (HE) is a complex neuropsychiatric syndrome affecting patients with liver diseases, mainly those with liver cirrhosis. The mildest form of HE is minimal HE (MHE), with mild cognitive impairment, attention deficit, psychomotor slowing and impaired visuo-motor and bimanual coordination. MHE may progress to clinical HE with worsening of the neurological alterations which may lead to reduced consciousness and, in the worse cases, may progress to coma and death. HE affects several million people in the world and is a serious health, social and economic problem. There are no specific treatments for the neurological alterations in HE. The mechanisms underlying the cognitive and motor alterations in HE are beginning to be clarified in animal models. These studies have allowed to design and test in animal models of HE new therapeutic approaches which have successfully restored cognitive and motor function in rats with HE. In this article we review the evidences showing that.
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Affiliation(s)
- Ana Agusti
- Fundación Investigación Hospital Clínico de Valencia. Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain
| | - Marta Llansola
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | | | - Andrea Cabrera-Pastor
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain
| | - Carmina Montoliu
- Fundación Investigación Hospital Clínico de Valencia. Instituto de Investigación Sanitaria-INCLIVA, Valencia, Spain
| | - Vicente Felipo
- Laboratory of Neurobiology, Centro de Investigación Príncipe Felipe, Valencia, Spain.
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21
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Ampuero J, Simón M, Montoliú C, Jover R, Serra MÁ, Córdoba J, Romero-Gómez M. Minimal hepatic encephalopathy and critical flicker frequency are associated with survival of patients with cirrhosis. Gastroenterology 2015; 149:1483-9. [PMID: 26299413 DOI: 10.1053/j.gastro.2015.07.067] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/29/2015] [Accepted: 07/17/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Minimal hepatic encephalopathy (MHE) is associated with falls, traffic accidents, and overt HE. However, the association with survival is controversial. We assessed the effects of MHE on the long-term survival of patients with cirrhosis. METHODS We performed a prospective study of 117 consecutive patients with cirrhosis seen at a tertiary hospital in Seville, Spain (estimation cohort), followed by a validation study of 114 consecutive patients with cirrhosis seen at 4 hospitals in Spain from January 2004 through December 2007. Patients were examined every 6 months at outpatient clinics through December 2013 (follow-up periods of 5 ± 2.8 y and 4.4 ± 3.9 y for each group, respectively). Cirrhosis was identified by liver biopsy, ultrasound, endoscopic analysis, and biochemical parameters. Liver dysfunction was determined based on model for end-stage liver disease (MELD) and Child-Pugh scores. All patients were administered the critical flicker frequency (CFF) test and psychometric hepatic encephalopathy scores were used to detect MHE. Survival curves were compared using the log-rank test and multivariable analysis was performed using Cox proportional hazards models. RESULTS The distributions of Child-Pugh scores were as follows: 66% class A, 31% class B, and 3% class C in the estimation cohort, and 50% class A, 32% class B, and 18% class C in the validation cohort. In the estimation cohort, 24 of 35 patients (68.6%) with a CFF score less than 39 Hz survived for 5 years, whereas 50 of 61 patients (82%) with a CFF score of 39 Hz or higher survived during the follow-up period (log-rank score, 5.07; P = .024). Psychometric hepatic encephalopathy scores did not correlate with survival. In multivariable analysis, older age (hazard ratio [HR], 1.07; 95% confidence interval [CI], 1.02-1.12; P = .009), CFF score less than 39 Hz (HR, 4.36; 95% CI, 1.67-11.37; P = .003), and MELD score (HR, 1.40; 95% CI, 1.21-1.63; P = .0001) were associated independently with survival during the follow-up period. In the validation cohort, CFF score less than 39 Hz and MELD score also were associated with patient survival during the follow-up period. MHE had no effect on the survival of patients with MELD scores less than 10 (among patients with CFF scores ≥39 Hz, 94.5% survived for 5 years vs 91.9% of patients with CFF scores <39 Hz; log-rank score, 0.64; P = .423). Fewer patients with MELD scores of 10-15 and MHE survived for 5 years (44.4%; 12 of 27) than those with MELD scores greater than 15 without MHE (61.5%; 8 of 13) (P < .05). Only 2 of 12 patients (16.7%) with MELD scores of 15 or higher and MHE survived for 5 years (log-rank score, 90.56; P = .0001). CONCLUSIONS MHE is associated with a reduced 5-year survival rate of patients with cirrhosis. Evaluation of MHE could help predict survival times and outcomes of patients with specific MELD scores. The CFF could help physicians determine prognoses of patients with cirrhosis.
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Affiliation(s)
- Javier Ampuero
- Unit for the Clinical Management of Digestive Diseases and Centro de Investigación Biomédica de Enfermedades Hepáticas y Digestivas, Valme University Hospital, Sevilla, Spain
| | - Macarena Simón
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | | | - Rodrigo Jover
- Gastroenterology Department, Hospital General Universitario, Alicante, Spain
| | | | - Juan Córdoba
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebrón, Barcelona, Spain
| | - Manuel Romero-Gómez
- Unit for the Clinical Management of Digestive Diseases and Centro de Investigación Biomédica de Enfermedades Hepáticas y Digestivas, Valme University Hospital, Sevilla, Spain.
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Abstract
Minimal hepatic encephalopathy (mHE) is diagnosed in patients with severe liver disease but no clinical symptoms of encephalopathy if either neuropsychological or neurophysiological tests indicate cerebral dysfunction and other possible causes of brain dysfunction have been excluded. mHE is characterized by deficits in attention, visuospatial orientation, visuoconstructive abilities and motor function. Accordingly, mHE can be expected to interfere with a subject's working ability, especially in those occupations that require handiwork, and driving ability. Indeed, about 60% of blue-collar workers with mHE have been shown to be assessed as unfit for work compared to only 20% of white-collar workers, and about 50% of patients with mHE have been judged unfit to drive a car in several studies. mHE interferes with a patient's quality of life and is associated with an increased risk of developing overt HE as well as increased mortality. Whether mHE is of importance for cognitive function after liver transplantation has still to be clarified.
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Weissenborn K. Diagnosis of minimal hepatic encephalopathy. J Clin Exp Hepatol 2015; 5:S54-9. [PMID: 26041959 PMCID: PMC4442856 DOI: 10.1016/j.jceh.2014.06.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Accepted: 06/05/2014] [Indexed: 12/12/2022] Open
Abstract
Minimal hepatic encephalopathy (mHE) has significant impact upon a liver patient's daily living and health related quality of life. Therefore a majority of clinicians agree that mHE should be diagnosed and treated. The optimal means for diagnosing mHE, however, is controversial. This paper describes the currently most frequently used methods-EEG, critical flicker frequency, Continuous Reaction time Test, Inhibitory Control Test, computerized test batteries such as the Cognitive Drug Research test battery, the psychometric hepatic encephalopathy score (PHES) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)-and their pros and cons.
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Key Words
- CDR, cognitive drug research
- CFF, critical flicker frequency
- CRT, continuous reaction time test
- EEG, electroencephalography
- ICT, inhibitory control test
- PHES, psychometric hepatic encephalopathy score
- PSE, portosystemic encephalopathy
- RBANS, repeatable battery for the assessment of neuropsychological status
- TA, target accuracy
- WL, weighted lures
- diagnostic means
- diagnostic use
- mHE, minimal hepatic encephalopathy
- minimal hepatic encephalopathy
- sensitivity
- specificity
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Affiliation(s)
- Karin Weissenborn
- Address for correspondence: Karin Weissenborn, Department of Neurology, Hannover Medical School, 30623 Hannover, Germany. Tel.: +49 511 532 2339; fax: +49 511 532 3115.
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Zhang XD, Zhang LJ, Wu SY, Lu GM. Multimodality magnetic resonance imaging in hepatic encephalopathy: An update. World J Gastroenterol 2014; 20:11262-11272. [PMID: 25170210 PMCID: PMC4145764 DOI: 10.3748/wjg.v20.i32.11262] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 01/29/2014] [Accepted: 05/29/2014] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a neuropsychiatric complication of cirrhosis or acute liver failure. Currently, HE is regarded as a continuous cognitive impairment ranging from the mildest stage, minimal HE to overt HE. Hyperammonaemia and neuroinflammation are two main underlying factors which contribute to the neurological alterations in HE. Both structural and functional impairments are found in the white mater and grey mater involved in HE. Although the investigations into HE pathophysiological mechanism are enormous, the exact pathophysiological causes underlying HE remain controversial. Multimodality magnetic resonance imaging (MRI) plays an important role in helping to understand the pathological process of HE. This paper reviews the up-to-date multimodality MRI methods and predominant findings in HE patients with a highlight of the increasingly important role of blood oxygen level dependent functional MRI.
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